Provider Demographics
NPI:1750986576
Name:TATUM, RUSSIA MARIA
Entity type:Individual
Prefix:DR
First Name:RUSSIA
Middle Name:MARIA
Last Name:TATUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17000 FAIRWAY VIEW LN
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-3463
Mailing Address - Country:US
Mailing Address - Phone:240-751-8256
Mailing Address - Fax:
Practice Address - Street 1:13600 JEFFERSON DAVIS HWY
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-2018
Practice Address - Country:US
Practice Address - Phone:703-494-3126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202219073183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist